University of Illinois Extension



|Name | |Birthdate | |

|Address | |

|4-H Club | |Year joined 4-H | |

|Unit 16 Logan, Menard & Sangamon County 4-H Member Record (11 – 13 year olds) |

|Year |Number of meetings |Club Offices Held |Committees worked on |

| |Held Attended | | |

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|Check box below for 4-H Categories you have enrolled in and are submitting records for |

|☐ |Achievement (MUST include a separate “Story” to be considered for this award category) |

|☐ |Animal Science (includes Beef, Cat, Dairy, Dog, Goat, Horse & Pony, Poultry, Rabbit, Sheep, Small Pets, Swine, and Vet Science) |

|☐ |Community Involvement & Global Awareness (includes Citizenship, Intercultural, Service Learning) |

|☐ |Engineering & Technology (includes Aerospace, Bicycle, Computer Science, Electricity, Geospatial, Robotics, Small Engines, Tractor, Video/Filmmaking, Welding, Woodworking) |

|☐ |Environment & Natural Resources (Entomology, Forestry, Geology, Natural Resources, Outdoor Adventures, Shooting Sports, Sportfishing, Wildlife) |

|☐ |Food, Nutrition & Health (includes 4-H Cooking 101, 201, 301, 401, Microwaving, Food Preservation, Health & Fitness) |

|☐ |Home & Family (includes Child Development, Consumer Education, Entrepreneurship, Intergenerational, Interior Design, Sewing & Textiles) |

|☐ |Personal Development (Communication, Journalism, Leadership, Photography, Public Presentations, Scrapbooking, Theater Arts, Video/Film, Visual Arts) |

|☐ |Plants & Soils (includes Crops, Floriculture, Horticulture, Plant & Soil Science) |

|Enter all projects you are enrolled in for a specific project category below. (ONE |PROJECT CATEGORY: |

|PROJECT CATEGORY PER PAGE): |(see first page for category titles) |

|Year(s) |Project Title |Made/Created/Grown, etc. |Exhibited |Workshops/Classes |Talks/Demos/Service |

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|4-H Skills: Enter skills you have learned in this project area (for each project in this Category you are enrolled in) in columns provided below. |

|Year(s) |Project Title |Skills Learned |

|EXAMPLE: | | |

|2013-2014 |Visual Arts |To use Sculpey clay, to bake clay, drying flowers, shading with pencil for sketching, to paint with acrylics, to arrange paper into a mosaic |

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|4-H Story: Write your story for this project category in box provided below (include information on all projects you are enrolled in for this category). Be sure to write about what you accomplished in the project |

|category this year, what you liked best in this project area this year, mention any challenges you might have faced, and what you’d like to do next year. ONE PROJECT CATEGORY STORY PER PAGE. |

|PROJECT CATEGORY (see first page of records for Project Category Titles): |

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|Enter all projects you are enrolled in for a specific project category below. (ONE |PROJECT CATEGORY: |

|PROJECT CATEGORY PER PAGE): |(see first page for category titles) |

|Year(s) |Project Title |Made/Created/Grown, etc. |Exhibited |Workshops/Classes |Talks/Demos/Service |

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|4-H Skills: Enter skills you have learned in this project area (for each project in this Category you are enrolled in) in columns provided below. |

|Year(s) |Project Title |Skills Learned |

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|4-H Story: Write your story for this project category in box provided below (include information on all projects you are enrolled in for this category). Be sure to write about what you accomplished in the |

|project category this year, what you liked best in this project area this year, mention any challenges you might have faced, and what you’d like to do next year. ONE PROJECT CATEGORY STORY PER PAGE. |

|PROJECT CATEGORY (see first page of records for Project Category Titles): |

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|Enter all projects you are enrolled in for a specific project category below. (ONE |PROJECT CATEGORY: |

|PROJECT CATEGORY PER PAGE): |(see first page for category titles) |

|Year(s) |Project Title |Made/Created/Grown, etc. |Exhibited |Workshops/Classes |Talks/Demos/Service |

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|4-H Skills: Enter skills you have learned in this project area (for each project in this Category you are enrolled in) in columns provided below. |

|Year(s) |Project Title |Skills Learned |

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|4-H Story: Write your story for this project category in box provided below (include information on all projects you are enrolled in for this category). Be sure to write about what you accomplished in the |

|project category this year, what you liked best in this project area this year, mention any challenges you might have faced, and what you’d like to do next year. ONE PROJECT CATEGORY STORY PER PAGE. |

|PROJECT CATEGORY (see first page of records for Project Category Titles): |

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|Enter all projects you are enrolled in for a specific project category below. (ONE |PROJECT CATEGORY: |

|PROJECT CATEGORY PER PAGE): |(see first page for category titles) |

|Year(s) |Project Title |Made/Created/Grown, etc. |Exhibited |Workshops/Classes |Talks/Demos/Service |

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|4-H Skills: Enter skills you have learned in this project area (for each project in this Category you are enrolled in) in columns provided below. |

|Year(s) |Project Title |Skills Learned |

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|4-H Story: Write your story for this project category in box provided below (include information on all projects you are enrolled in for this category). Be sure to write about what you accomplished in the |

|project category this year, what you liked best in this project area this year, mention any challenges you might have faced, and what you’d like to do next year. ONE PROJECT CATEGORY STORY PER PAGE. |

|PROJECT CATEGORY (see first page of records for Project Category Titles): |

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|Participation, Leadership, Community Service not related to a specific 4-H project |

|Mark each event with Local Club (L), County (C), Unit/Multicounty (M), State (S) and the number attended |

|List PARTICIPATION such as workshops, conferences and camps not specific to a project in rows below. |

|Year |Activity/Event |

|EXAMPLE: | |

|2013-2014 |Attended 4-H Camp (M, 250); County International Night Program (C,20); 4-H Club Bowling Party (L,25) |

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|List LEADERSHIP such as Club Offices, club talk, leading club activity, or serving as ambassador which are not specific to a project in rows below. |

|Year |Activity/Event |

|EXAMPLE: | |

|2013-2014 |Club Reporter (L, 25); gave club talk about 4-H Camp (L,20); 4-H County Ambassador (C, 15) |

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|List COMMUNITY SERVICE or 4-H PROMOTION (such as appearance in newspaper, tv, radio) not specific to a project in rows below. |

|Year |Activity/Event |

|EXAMPLE: | |

|2013-2014 |4-H Club National 4-H Week Activity (L,12); pictured in Food Show Results in paper (C,12); donated food to club food drive (L, 20); helped at 4-H promo booth at Fair (C,10) |

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|Non-Extension Related Activities |

|Summarize what you have done in your school, community, and church activities. (Participation, Leadership, and Community Service) |

|List PARTICIPATION in School, Community & Church events in rows below. (see example below) |

|Year |Location |Event/Activity |

|EXAMPLE |School |Spelling Bee, Basketball Team |

|2013-2014 |Community |Boy Scouts, Music Recital, Swim Lessons |

| |Church |Children’s Choir, Youth Group |

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|List LEADERSHIP in School, Community & Church events in rows below. (see example below) |

|Year |Location |Event/Activity |

|EXAMPLE |School |Student Council Representative, Scholastic Bowl Captain |

|2013-2014 |Community |Organized Food Drive for Scouts |

| |Church |VBS Group Leader |

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|List COMMUNITY SERVICE ACTIVITIES in School, Community & Church in rows below. (see example below) |

|Year |Location) |Event/Activity |

|EXAMPLE |School |Collected money for St. Jude |

|2013-2014 |Community |Visited Nursing Home Residents |

| |Church |Collected items for food drive at church |

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|APPROVAL |

|Year |Member Signature |Parent/Guardian Signature |Leader Signature |

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